Prior Authorization of Power Mobility Devices (PMD) Demonstration

CMS is launching a prior authorization of power mobility devices demonstration project in CA, IL, MI, NY, NC, FL and TX. This project is expected to begin on September 1, 2012. CMS believes this demonstration will lead to reductions in improper payments for power mobility devices, which will help ensure the sustainability of the Medicare Trust Funds and protect beneficiaries who depend upon the Medicare Program. In addition, this demonstration will help ensure that a beneficiary’s medical condition warrants their medical equipment under existing coverage guidelines. Medicare covers scooters and power wheelchairs (PMDs) when it is needed by the beneficiary to perform activities of daily living in the home and other devices (canes, walkers, manual wheelchairs) are not sufficient. However, power mobility devices are sometimes provided when not medically necessary and have a history of fraud and abuse. CMS is using this opportunity to reduce waste and abuse in the Medicare program. CMS will be holding an Open Door Forum Call on August 29th.

What items are included in the demonstration?

Under this demonstration, for beneficiaries who reside in one of the demonstration states, CMS will have a prior authorization process for the following items paid by Medicare:

All Power Operated Vehicles

All standard power wheelchairs

All group 2 complex rehabilitative power wheelchairs

All group 3 complex rehabilitative power wheelchairs without power options

All pediatric and group 4 power wheelchairs

Miscellaneous power wheelchairs

Group 3 complex rehabilitative power wheelchairs with power options are excluded.

As a physician, what do I need to do?

The physician/treating practitioner should submit the prior authorization request. Alternatively, the supplier, acting on behalf of the physician/treating practitioner, may perform this administrative function and submit the request. The submitter must send a copy of the face-to-face evaluation and the 7-element prescription to the supplier (described below) within 45 days from the completion of the face-to-face mobility exam. After the supplier receives the order and documentation, the Durable Medical Equipment Medicare Administrative Contractor will make every effort to review and communicate a decision within 10 business days for initial submissions and 20 days for resubmissions on whether the PMD meets all Medicare coverage requirements. There will be a mechanism in place to request an expedited 48 hour review, in emergency situations. The supplier will prepare a detailed product description that describes the item(s) being provided including all options and accessories. The physician/treating practitioner should review the document, and sign, date and return it to the supplier if the physician agrees with what is being provided. If the physician does not agree with the detailed product description, contact the supplier to clarify what the beneficiary needs.

Medicare does provide physicians additional reimbursement (HCPCS code G0372) to recognize the additional time and effort that are required to provide this documentation to the supplier. This code is payable in addition to the reimbursement for your E&M visit code.

What documentation is required?

In order for Medicare to provide reimbursement for a PMD, there are several statutory requirements that must be met.

There must be an in-person visit with a physician specifically addressing the patient’s mobility needs. This is often referred to as the “face to face examination.”

There must be a history and physical examination by the physician or other medical professional focusing on an assessment of the patient’s mobility limitation and needs. The results of this evaluation must be recorded in the patient’s medical record. The history should paint a picture of the patient’s functional abilities and limitations on a typical day and should contain as much objective data as possible.

A prescription must be written AFTER the in-person visit has occurred and the medical evaluation is completed. This prescription has seven required elements:

Beneficiary’s name

Description of the item that is ordered. This may be general e.g. “power operated vehicle,” “power wheelchair,” or “power mobility device” – or may be more specific.

Date of completion of the face to face examination

Pertinent diagnoses/conditions that relate to the need for the PMD

Length of need

Physician’s signature

Date of physician signature

The prescription and medical records documenting the in-person visit and evaluation must be sent to the equipment supplier within 45 days after the completion of the evaluation.